The MRI features discussed include synovitis, tendonitis, dactylitis, bone oedema, bone erosions, soft tissue oedema, spondylitis/ sacroiliitis and subclinical arthropathy.. Bone oedema
Trang 1DIP = distal interphalangeal; FS = fat saturated; MRI = magnetic resonance imaging; PIP = proximal interphalangeal; PsA = psoriatic arthritis; RA = rheumatoid arthritis; SpA = spondyloarthropathy; STIR = short tau inversion recovery
Abstract
Psoriatic arthritis is a diverse condition that may be characterized
by peripheral inflammatory arthritis, axial involvement, dactylitis and
enthesitis Magnetic resonance imaging (MRI) allows visualization
of soft tissue, articular and entheseal lesions, and provides a
unique picture of the disease process that cannot be gained using
other imaging modalities This review focuses on the literature on
MRI in psoriatic arthritis published from 1996 to July 2005 The
MRI features discussed include synovitis, tendonitis, dactylitis,
bone oedema, bone erosions, soft tissue oedema, spondylitis/
sacroiliitis and subclinical arthropathy Comparisons have been
drawn with the more extensive literature describing the MRI
features of rheumatoid arthritis and ankylosing spondylitis
Introduction
Magnetic resonance imaging (MRI) has advanced our
under-standing of many types of arthritis, both with respect to
inflammatory processes and articular damage Psoriatic
arthritis (PsA) has received less research scrutiny than
rheumatoid arthritis (RA) in many areas, including imaging [1],
but this is likely to change because MRI outcome measures
are increasingly being used in clinical trials of new therapeutic
agents such as biologics [2] In this review we summarize the
literature describing the MRI features of articular and
entheseal disease in PsA and include references to
histopathological correlates where this information is available
Very few published studies have concentrated specifically on
PsA, and most data come from studies of broader groups of
patients with ‘inflammatory arthritis’ or ‘spondyloarthropathies’
(SpAs) and from case reports and small case series
Method
A Medline/Embase search was undertaken from 1966 to July
2005 using the following search words; EXP arthritis,
psoriatic, magnetic resonance imaging, magnetic resonance,
psoriasis and combinations thereof A total of 264 hits
resulted, and of these 20 reports were regarded as useful (category 1, Table 1) but two could not be obtained from library serial collections or electronically
Twelve more articles were found by hand searching and were included in the source material for this review Of the 30 articles finally identified [3-32], 24 dealt with MRI of peripheral joints or entheses and six with axial joints Table 2 classifies these articles alphabetically (by first author) and describes the type of study, number of patients examined and field strength of MRI machine used The review has been organised according to the various MRI characteristics of PsA, including synovitis, bone erosion and bone oedema, enthesitis, tenosynovitis and dactylitis, spondylitis/sacroiliitis and subclinical disease
Results and discussion
Synovitis
Histopathological studies have suggested that the inflamed synovial membrane of PsA differs in certain subtle ways from rheumatoid synovium with less lining layer hyperplasia, more subsynovial oedema and a greater number of synovial vessels per square millimetre [33] However, on MRI, PsA synovitis appears indistinguishable from that of RA Cimmino and coworkers [9] recently used dynamic MRI of the wrist using a 0.2 T dedicated-extremity scanner to address this question The rate of increase in enhancement following contrast injection did not differ between PsA and RA patients when they were matched for disease activity, but in both groups it was higher than in normal control individuals The authors concluded that dynamic MRI cannot be used diagnostically to differentiate PsA from RA Similar findings were described by Antoni and coworkers [3], who used dynamic-enhanced MRI
to quantify synovitis in 10 PsA patients before and after infliximab treatment Contrast enhancement was markedly
Review
Magnetic resonance imaging in psoriatic arthritis:
a review of the literature
Fiona McQueen1, Marissa Lassere2and Mikkel Østergaard3
1Department of Molecular Medicine and Pathology, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
2Department of Rheumatology, St George Hospital, University of New South Wales, New South Wales, Australia
3Department of Rheumatology, Copenhagen University Hospitals at Hvidovre and Herlev, Copenhagen, Denmark
Corresponding author: Fiona McQueen, f.mcqueen@auckland.ac.nz
Published: 23 March 2006 Arthritis Research & Therapy 2006, 8:207 (doi:10.1186/ar1934)
This article is online at http://arthritis-research.com/content/8/2/207
© 2006 BioMed Central Ltd
Trang 2reduced following anti-tumour necrosis factor-α therapy,
consistent with other reports that this cytokine plays a major
role in psoriatic skin and joint pathology [34]
Others have measured PsA synovitis on static magnetic
resonance scans Savnik and coworkers [28] used manual
outlining of synovial membrane to quantify synovitis in their
study of 84 patients with inflammatory arthritis, 18 of whom
had reactive arthritis or PsA MRI of the wrist and finger joints
(metacarpophalangeal [MCP], proximal interphalangeal [PIP]
and distal interphalangeal [DIP] joints) was performed using
0.2 T and 1.5 T scanners They noted that the volume of
synovial membrane was increased but did not change
significantly over 1 year, contrasting with RA patients, in
whom it fell in response to therapy Jevtic and coworkers [12]
(using a 2.35 T magnet) described MRI of the finger joints in
a group of 13 patients with PsA, three with Reiter’s syndrome
and 16 with RA Although in some PsA patients synovitis was
observed to conform to a typical rheumatoid pattern, in others
there was ‘inflamed tissue extending far beyond the joint
capsule, involving neighbouring structures such as thickened
collateral ligaments and surrounding periarticular soft tissue’
McGonagle and colleagues [35] went on to describe in
greater detail the MRI features of enthesitis that may be seen
in association with synovitis in PsA (see below), and
postulated that true PsA can be distinguished from RA with
concomitant psoriasis on these grounds Examples of PsA
synovitis and associated extracapsular/soft tissue lesions are
shown in Figures 1 and 2
Bone erosions and bone oedema
Although the work conducted by Ritchlin and coworkers [36]
recently focused attention on activated osteoclasts in PsA
and raised the possibility that a disorder of bone remodelling
may underlie this disease, evidence from MRI studies
conducted thus far suggests that PsA erosions are rather
similar to RA erosions [4,27] There are differences in terms
of distribution, with involvement of non-RA sites such as DIP
joints and entheseal insertions [37], but the erosions
themselves consist of a break in cortical bone overlying a region of altered signal intensity with definite margins, as described in RA [38] Also, as in RA, PsA erosions can be large and are frequently not visualized on conventional radio-graphy [30] The study conducted by Savnik and coworkers [28] in patients with inflammatory arthritis suggested that MRI erosions in PsA patients did not progress over time to the same extent as those in patients with early RA, raising the possibility that PsA bone disease may sometimes be less aggressive Backhaus and colleagues [4] included 15 PsA patients in their study of MRI, ultrasound and scintigraphy of the finger joints, nine of whom were described as having MRI erosions Some of these were ‘nonenhancing’ following contrast injection, suggesting that they may have contained fibrous tissue rather than inflammatory pannus and be relatively ‘inactive’, but a clear description of these lesions was not given
As in RA, the histopathological correlate of MRI bone oedema has not been defined in PsA, but Bollow and coworkers [6] found some evidence of osteitis in subcortical bone in their biopsy study of sacroiliac joints in SpA patients (including two with PsA) Bone oedema has been described
in PsA, reactive arthritis, ankylosing spondylitis and RA [6,27,39] and is recognized as an ill defined area in the subcortical bone with increased signal on short tau inversion recovery (STIR), T2 weighted with fat saturation (FS) and postcontrast T1 weighted with FS sequences [38] Savnik and colleagues [27] found MRI bone oedema in PsA patients included in their cohort with early inflammatory arthritis, and observed that the total number of bones affected did not change over 1 year (compared with the RA patients, in whom
it increased) [27] They found examples of PsA bone oedema involving distal, middle and proximal phalanges of the fingers
as well as carpal bones, radius and ulna, and described that
in various cases it either appeared or disappeared between the baseline and 1 year magnetic resonance examinations Bone oedema was a strong predictor of bone erosions in their RA group (as was described elsewhere [39]), but this
Table 1
Criteria used for Medline/Embase search
2 Review: not in Medline/Embase but found via hand search and meets criteria for MRI and PsA 12
MRI, magnetic resonance imaging; PsA, psoriatic arthritis
Trang 3was not specifically demonstrated in PsA joints and further
studies are needed to clarify this point
In their series comparing MRI of the hand in 28 PsA and 18
RA patients, Giovagnoni and coworkers [10] also noted
signal change in subchondral bone (bone oedema) in 43% of
their patients associated with pronounced periarticular
oedema of the soft tissues, spreading to the subcutis, and felt this might constitute a ‘psoriatic pattern’ on MRI Jevtic and colleagues [12] described extensive MRI bone oedema involving the proximal phalanx in a patient with Reiter’s syndrome (which is of interest because the radiographic features of this condition are said to be identical to those of PsA [40]) and also identified inflammatory changes in
Table 2
Source material for review: articles dealing with MRI examination of PsA
PsA patients MRI who field underwent strength
Antoni [3] 2002 1 Open-label study of infliximab in PsA; dynamic MRI of hands or feet 10 1.5
Bollow [6] 2000 2 SpA patients; biopsies compared with MRI of sacroiliac joints 2 1.5 Bongartz [7] 2005 5 Psoriatic onycho-pachydermo periostitis; MRI evaluation 1 Not stated
Maillefert [13] 2003 3 Patients with inflammatory arthritis; MRI of hindfoot 1 1.5 McGonagle [14] 1998 2 SpA and RA patients with knee effusion; MRI evaluation 3 0.5 and
1.5 McGonagle [15] 2002 2 Patients with plantar fasciitis (SpA and mechanical); MRI of entheses 4 0.5 and
1.5 Melchiorre [16] 2003 2 PsA and RA patients; MRI of temporomandibular joint 11 0.5
Offidani [18] 1998 4 Patients with psoriasis and no joint pain; MRI of hands 25 1.0 Olivieri [19] 1996 2 SpA patients with dactylitis; MRI of fingers Not stated 0.5 Olivieri [20] 1997 2 SpA patients with dactylitis of the toes; MRI of toes 6 0.5 Olivieri [21] 2002 2 PsA patients with dactylitis of the fingers; MRI of fingers 6 1.5 Olivieri [22] 2003 5 PsA Patient with dactylitis of fingers; MRI of fingers 1 Not stated
Padula [24] 1999 5 Patient with psoriasis and tenosynovitis; MRI evaluation 1 Not stated Salvarani [25] 1999 5 Patients with peripheral pitting oedema; MRI evaluation 2 Not stated Savnik [26] 2001 2 Patients with inflammatory arthritis; high field versus low field MRI Not stated 0.2 and
Savnik [27] 2001 2 Patients with inflammatory arthritis (RA and SpA); MRI of wrists and fingers 8 1.5 Savnik [28] 2002 3 Patients with inflammatory arthritis (RA and SpA); MRI of wrists and fingers, Not stated 0.2 and
Taylor [29] 1997 5 PsA patient with enthesitis of elbow; MRI evaluation 1 Not stated Tehranzadeh [30] 2004 2 Patients with inflammatory arthritis; MRI of hand evaluated for large bony lesions 7 1.5 Tuzun [31] 1996 5 Psoriatic spondylitis mimicking spinal brucellosis; MRI of spine 1 Not stated Williamson [32] 2004 2 PsA patients with clinical features of sacroiliitis; MRI of sacroiliac joints 68 1.0
a1, Clinical trial; 2, Observational, cross-sectional; 3, Observational, longitudinal; 4, Case–control; 5, Case report MRI, magnetic resonance
imaging; PsA, psoriatic arthritis; RA, rheumatoid arthritis; SpA, spondyloarthropathy
Trang 4overlying soft tissues McGonagle and coworkers [14]
stressed the association between MRI bone oedema and
evidence of enthesitis at the knee, and this is described in
more detail below Most recently, in a case report [7],
prominent MRI bone oedema was described in a patient with
psoriatic onycho-pachydermo periostitis affecting the toes
Both clinical tissue swelling and MRI bone oedema resolved
dramatically in response to adalimumab, suggesting an
underlying tumour necrosis factor-α mediated process
Figure 2 shows an example of bone oedema from a patient
with the mutilans form of PsA There is extensive bone
oedema involving the head of the proximal phalanx and
extending down the shaft of the bone On the distal aspect of
the joint a well circumscribed lesion with increased signal is
likely to represent an erosion Erosions are also apparent in
Figure 1 involving PIP and DIP joints
Enthesitis
Barozzi and coworkers [41] described the MRI features of
enthesitis as being characterized by ‘swelling [of the
entheseal region] and deviation from the normally uniform low
signal intensity of tendons and ligaments, [with] distension of
adjacent bursae by fluid collection, peritendinous soft tissue
swelling and inflammation of bone adjacent to the insertion’
McGonagle and colleagues [14] described these findings in
their MRI study of 10 SpA patients (three of whom had PsA)
with knee swelling of recent onset They observed increased
signal on T2 weighted images, characterizing ‘focal
extra-capsular fluid/oedema’ in entheseal portions of the patellar tendon, the iliotibial band and adjacent to the posterior capsule of the knee Perientheseal bone marrow oedema was present in six SpA patients, including one with PsA, in whom
it involved bone at the tibial plateau as well as bony attachments of the patellar tendon and posterior cruciate ligament The same group also studied calcaneal enthesopathy in 17 early SpA patients (including four with PsA), and similar findings were described, again often including underlying bone marrow oedema [15] However, Jevtic and coworkers [12], describing magnetic resonance features of peripheral PsA in the hands, noted that bone oedema was present adjacent to regions of enthesitis in fewer than 50% of patients, indicating that these features are not always observed together
Godfrin and colleagues [11] described a study of SpA patients (including six with PsA) who had entheseal pain MRI revealed typical abnormalities at entheses, all of which corresponded to hot spots on radionuclide scans These authors noted that T2 weighted sequences appeared less
Figure 1
Magnetic resonance images of fingers: psoriatic arthritis Shown are
T1-weighted (a) precontrast and (b) postcontrast coronal magnetic
resonance images of the fingers in a patient with psoriatic arthritis
Enhancement of the synovial membrane at the third and fourth proximal
interphalangeal (PIP) and distal interphalangeal (DIP) joints is seen,
indicating active synovitis (large arrows) There is joint space
narrowing with bone proliferation at the third PIP joint and erosions are
present at the fourth DIP joint (white circle) Extracapsular
enhancement (small arrows) is seen medial to the third and fourth PIP
joints, indicating probable enthesitis Note that this particular slice
does not allow optimal visualization of all of the mentioned pathologies
Figure 2
Magnetic resonance image of index finger: psoriatic arthritis (mutilans form) Shown is a T2 weighted fat suppressed sagittal image of the index finger in a patient with PsA (mutilans form) Focal increased signal (probable erosion) is seen at the base of the middle phalanx (long thin arrow) There is synovitis at the proximal interphalangeal joint (long thick arrow) plus increased signal in the overlying soft tissues indicating oedema (short thick arrow) There is also diffuse bone oedema (short thin arrows) involving the head of the proximal phalanx and extending distally down the shaft
Trang 5sensitive than post-gadolinium FS T1 weighted and STIR
sequences for detecting MRI enthesitis Interestingly, one
patient presenting with pelvic pain and MRI changes of
enthesitis at the anteroinferior iliac spine subsequently went
on to develop full-blown PsA, which is consistent with other
reports that isolated entheseal pain may be a first
presentation of this disease [29] Figure 3 shows an example
of enthesitis at the Achilles tendon insertion, with erosion and
marrow oedema in the adjacent bone
Dactylitis, tendonitis and soft tissue oedema
Common to all forms of SpA but not a feature of RA, dactylitis
is one of the more important clinical features that define PsA
and is described in about one-third of patients [37] Olivieri
and coworkers have described several series of patients with
dactylitis involving the fingers and toes [19-22] and
demonstrated that tenosynovitis, usually with effusion, is
invariably present Flexor tendons were more often involved
than extensor tendons, and they found concomitant small
joint synovitis to be relatively uncommon (ranging from 6% to
27% of cases) and not a ‘sine qua non for the
sausage-shaped feature’ [22] Following the report of McGonagle and
colleagues [14] that suggested that the primary abnormality
in PsA was entheseal, this group examined six PsA patients
with 11 dactylitic fingers for the presence of enthesitis [22]
Bone oedema was not observed at entheseal insertions of
flexor or extensor tendons, but peritendinous soft tissue
oedema contributed to digital swelling in a number of more
severe cases with what has been described as a
‘honeycomb’ appearance of the subcutaneous tissues on T2
weighted MRI sequences [8] Giovagnoni and coworkers
[10] also described ‘diffuse and pronounced periarticular soft
tissue oedema that spread to the subcutis’ in the hands of
86% of their PsA patients
As with other manifestations of PsA including skin disease and arthritis, trauma has been described as a trigger for the development of dactylitis via a ‘Koebner-type’ phenomenon [24] A case report described MRI evidence of extensive tenosynovitis and soft tissue oedema involving the fingers and hand, which followed a blow to the hand and eventually settled spontaneously [24] Figure 4 shows dactylitis in a PsA patient, due to florid flexor tenosynovitis An example of soft tissue oedema overlying synovitis at a PIP joint is shown in Figure 2
Psoriatic arthritis sacroiliitis and spondylitis
MRI is very sensitive for early detection of sacroiliitis in SpA Williamson and coworkers [32] showed that MRI-diagnosed sacroiliitis was present in 38% of a group of unselected PsA patients and was not necessarily associated with a clinical history of inflammatory back pain or positive sacroiliac provocation tests The MRI changes described were consis-tent with the findings presented by Bollow and coworkers [5] and included bone oedema, sacroiliac erosions and the more chronic changes of periarticular fat accumulation and sclerosis Muche and colleagues [17] conducted a detailed analysis of the MRI features of sacroiliitis in 93 SpA patients, including five with PsA (but their results were not analyzed separately) They confirmed that MRI sacroiliitis was very common in SpA, most often involving the dorsocaudal part of the joint in early disease in which subchondral bone oedema was a frequent finding Figure 5 shows an example of MRI sacroiliitis in a patient with PsA
There have been no MRI studies of the rest of the spine specifically in PsA, but in ankylosing spondylitis Braun and coworkers [42] determined that MRI bone oedema at vertebral margins was an indicator of disease activity and a
Figure 3
Sagittal magnetic resonance images of ankle region: psoriatic arthritis (a) Short tau inversion recovery (STIR) image, showing high signal intensity
at the Achilles tendon insertion (enthesitis, thick arrow) and in the synovium of the ankle joint (synovitis, long thin arrow) Bone marrow oedema is
seen at the tendon insertion (short thin arrow) (b,c) T1 weighted images of a different section of the same patient, before (panel b) and after (panel
c) intravenous contrast injection, confirm inflammation (large arrow) at the enthesis and reveal bone erosion at tendon insertion (short thin arrows)
Trang 6predictor of response to infliximab Radiographically, the
spondylitis of PsA and reactive arthritis differs from
ankylosing spondylitis in that osteophytes are chunky and
asymmetrical [43], and so exploration using MRI would be of
interest to determine whether there are disease specific
features Tuzun and colleagues [31] reported a case of
psoriatic spondylitis presenting with back pain complicated
by disc herniation MRI findings were florid, with high signal
on T2 weighted images involving large areas of the endplates
of adjacent vertebral bodies with an appearance suggestive
of infection (brucellosis was suspected) These changes
resolved following treatment with methotrexate Figure 6
shows a similar example with extensive bone oedema and
erosion at adjacent endplates
Subclinical disease
Offidani and coworkers [18] investigated a group of 25
patients with psoriasis, but no arthritic symptoms, for possible
subclinical MRI evidence of PsA and compared the findings
with those in a matched control population MRI scans from
68% of patients were positive for signs of arthritis including
joint or tendon sheath effusions, bone erosions and bone
oedema They concluded that there was a high incidence of
‘subclinical arthritis’ in patients with psoriasis alone, and
these findings agree with those from an earlier scintigraphic
study conducted in patients hospitalized with severe psoriatic
skin disease [44], which described increased periarticular
uptake of isotope at a number of joint regions An earlier
Mayo Clinic study [45] also noted a high incidence of PsA
occurring in 39% of patients with psoriasis, and
corroboration by the new MRI evidence may lead to estimates
of the frequency of PsA being upwardly revised
Conclusion
PsA shares clinical manifestations with RA and SpA, and this also applies to its MRI features Peripheral PsA synovitis appears similar to RA synovitis on static and dynamic MRI Likewise, PsA bone erosions do not have disease specific MRI features, but little is known concerning how they progress over time MRI bone oedema can involve any of the wrist or finger bones, where it may persist or be transient, but whether it is a predictor of erosions in PsA remains to be determined With enthesitis, dactylitis and spondylitis, the MRI features of PsA depart from those of RA and conform to
Figure 4
Magnetic resonance images of fingers: psoriatic arthritis with dactylitis
due to flexor tenosynovitis Shown are T1 weighted axial (a) precontrast
and (b) postcontrast magnetic resonance images of the fingers from a
patient with psoriatic arthritis exhibiting flexor tenosynovitis at the
second finger with enhancement and thickening of the tendon sheath
(large arrow) Synovitis is seen in the fourth proximal interphalangeal
joint (small arrow)
Figure 5
Magnetic resonance images of sacroiliac joints: psoriatic arthritis Shown are T1-weighted semi-coronal magnetic resonance images
through the sacroiliac joints (a) before and (b) after intravenous
contrast injection Enhancement is seen at the right sacroiliac joint (arrow), indicating active sacroiliitis
Trang 7the SpA group of disorders Enthesitis has been described
adjacent to peripheral and axial joints, often associated with
synovitis and sometimes with bone oedema Dactylitis has
been shown on magnetic resonance scans to be due to
tenosynovitis with effusion, sometimes associated with small
joint synovitis Diffuse soft tissue oedema may overlie areas of
dactylitis, synovitis, or bone oedema There are few MRI
studies in axial PsA but bone oedema appears to be a
sensitive sign of early sacroiliitis Finally, MRI has revealed
evidence of subclinical arthritis in a large proportion of
patients with psoriasis alone, suggesting that PsA could be a
much more common disorder than was previously suspected
Competing interests
The authors declare that they have no competing interests
Acknowledgements
Dr Charlotte Wiell, Copenhagen University Hospitals at Hvidovre and
Herlev, Denmark, is acknowledged for her contribution to the image
collection presented (Figures 1, 3 and 4)
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